Ann Thorac Surg 2007;83:293-294
© 2007 The Society of Thoracic Surgeons
Case Reports
Temporary Perfusion for Mesenteric Ischemia With Acute Type A Aortic Dissection
Yoshihiro Okada, MDa,*,
Mitsunori Okimoto, MDa,b,
Masayoshi Katsumata, MDb,
Shigeyasu Takeuchi, MDb
a Department of Translational Research for Healthcare and Clinical Science, Graduate School of Medicine, the University of Tokyo
b Department of Cardiovascular Surgery, Chiba Emergency Medical Center, Chiba, Japan
Accepted for publication April 6, 2006.
* Address correspondence to Dr Okada, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan (Email: okd-tky{at}umin.net).
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Abstract
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We report advantages of a temporary mesenteric perfusion method for bowel ischemia with acute type A aortic dissection. The perfusion catheter was inserted from the branch of the superior mesenteric artery. This technique was found to be useful in certain cases that require prompt visceral organ perfusion and proximal aortic repair, which enabled a simultaneous treatment for both lesions and a blood pressure evaluation.
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Introduction
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Although the surgical outcome of acute type A aortic dissection has been improved, the mortality rate continues to remain high when it occurs with visceral organ ischemia. We report our experience of simultaneous emergent bypass grafting of the superior mesenteric artery (SMA) with proximal aortic repair for acute aortic dissection. We used a technique of temporary perfusion to a branch of the SMA to measure arterial pressure as well as perfuse abdominal organs.
A 48-year-old man who was diagnosed with acute aortic dissection was referred to our center. The primary symptom was sudden onset of anterior chest pain, subsequently followed by gradual extension toward the abdomen and sensory disturbance of the bilateral lower extremities. The patient had severe abdominal pain with an emphatic tenderness without rebound tenderness, and also revealed bilateral leg ischemia. The contrast image of the computed tomographic scan revealed a dissecting aorta from the root to the terminal aorta. The true lumen was very narrow in the descending aorta and disappeared on being completely compressed by false lumen. The celiac artery and SMA had originated from the false lumen anatomy. The false lumen was well stained by contrast media. However, the SMA was not stained from the beginning, whereas the celiac artery was in contrast. At this point, we strongly suspected that inadequate blood flow of the SMA may lead to complete intestinal infarction; therefore we performed an emergent operation described as follows.
At first a laparotomy was performed followed by direct inspection of the abdominal organs. The liver was intact; however the small intestine was slightly cyanotic, and pulsation of the SMA could not be determined. We assessed the risk of ischemic necrosis of the intestine, and an emergent blood supply was required. The appropriate branch of the SMA was cannulated with a 14-guage soft catheter, which is usually used for central venous cannulation, and through this the arterial pressure was measured and perfusion was performed. The manometry showed 33 mm Hg pressure without pulsatile wave, whereas pressure of radial artery was 80/50 mm Hg. Subsequently we began an initial artery perfusion by a manual method using a syringe. Later the inflow channel was switched to the branch from the circuit of the cardiopulmonary bypass. Because the flow volume was not precisely measured, a visual check of the intestinal color was required. Next, proximal aortic procedures were started. A large intimal tear was located almost proximal to the origin of the brachiocephalic artery. The ascending aortic replacement was performed using the deep hypothermic circulatory arrest technique. After proximal aortic repair, we re-evaluated the mesenteric artery. Once the tip of the catheter was moved forward into the aorta, manometry revealed a pressure of 76 mm Hg; however, when it was drawn out to the SMA, the pressure decreased immediately to 22 mm Hg. We interpreted this phenomenon as an obstruction of the SMA orifice by the dissecting flap, and we performed saphenous vein bypass grafting from the right common iliac artery, which was not dissected, to the first branch of the SMA. Because the intestine showed a good color during all procedures, intestinal resection could be avoided.
Although a fasciotomy of the left leg was required due to a compartment syndrome, the patient recovered favorably. The angiography revealed patent saphenous vein graft and a narrow orifice of the SMA 3 weeks postoperatively (Fig 1). The patient did not show any symptoms of abdominal angina during the follow-up period of 2 years.
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Fig 1. The postoperative digital subtraction angiography shows the patent bypass graft (arrows) from right iliac artery to the first branch of the superior mesenteric artery (SMA). The orifice of the SMA is strictly narrow and it arises from the false lumen of the aorta.
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Comment
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Visceral ischemia combined with acute aortic dissection is a life-threatening condition, and the primary strategy for this condition arising due to type B dissection could be focused on a prompt topical revascularization in most cases. However, when visceral ischemia occurs with an acute type A dissection, it is difficult to make a prompt decision. Two major issues are associated with this condition. One is to determine which lesion should be treated first (ie, the proximal aorta or the visceral organ), and the other is the manner in which compromised arteries can be perfused. A primary aortic surgery has an increased risk of bowel infarction, which frequently leads to patient mortality [1], and a primary visceral revascularization out of the operating room is back on to the risk of an aortic rupture [2]. Although some successful treatments using percutaneous intraluminal fenestration or stenting have been reported, the criteria or degree of intestinal ischemia or infarction were unclear [3]. In fact, the exact diagnosis of intestinal ischemia is very difficult. The bowel can not be observed from the outside, and occlusion of either the SMA or the celiac artery does not directly indicate intestinal ischemia, because complexities of the collateral arteries are variable. Because the already infarcted bowel should be resected without any alternatives, the outcome of such cases can be improved by not ignoring the ongoing ischemia and by providing a fast-track perfusion for the lesion, and by performing timely proximal aorta repair. Then a simultaneous approach to both lesions is recommended in all cases [4].
Temporary perfusion is preferable in some cases. This technique would provide a prompt and certain perfusion and permit re-evaluation. Because simultaneous median sternotomy and laparotomy could be easily performed, the delay of treatments for both lesions is avoidable. The mechanisms of branch occlusion vary [5]; however, retrograde perfusion from the peripheral branch is effective regardless of the anatomy of the compromised branch, even if the fenestration could not achieve good results. Because the dissection flap is unsteady in an acute phase, and a branch obstruction is occasionally released after proximal aortic repair, the requirement for a permanent revascularization should be re-evaluated. The perfusion catheter inserted into the mesenteric branch could also be used for measuring the pressure. The exact criteria for manometry evaluation are not clear; however, with this supportive method, a prudent decision of whether a permanent bypass grafting is required or not can be made well in advance.
In conclusion, we propose an emergent direct inspection of the bowel concurrently with proximal aortic repair in such cases. When the intestine is moribund, a temporary perfusion is effective.
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References
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- Deeb GM, Williams DM, Bolling SF, et al. Surgical delay for acute type A dissection with malperfusion Ann Thorac Surg 1997;64:1669-1675discussion 75–7.[Abstract/Free Full Text]
- Slonim SM, Miller DC, Mitchell RS, Semba CP, Razavi MK, Dake, MD. Percutaneous balloon fenestration and stenting for life-threatening ischemic complications in patients with acute aortic dissection J Thorac Cardiovasc Surg 1999;117:1118-1126.[Abstract/Free Full Text]
- Lauterbach SR, Cambria RP, Brewster DC, et al. Contemporary management of aortic branch compromise resulting from acute aortic dissection J Vasc Surg 2001;33:1185-1192.[Medline]
- Okita Y, Takamoto S, Ando M, Morota T, Kawashima Y. Surgical strategies in managing organ malperfusion as a complication of aortic dissection Eur J Cardiothorac Surg 1995;9:242-246discussion 47.[Abstract]
- Williams DM, Lee DY, Hamilton BH, et al. The dissected aorta: percutaneous treatment of ischemic complications—principles and results J Vasc Interv Radiol 1997;8:605-625.[Medline]
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Abstract
Introduction
